Provider Demographics
NPI:1740869536
Name:O'BRIEN, CASEY NICOLE
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:NICOLE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-3134
Mailing Address - Country:US
Mailing Address - Phone:321-745-7920
Mailing Address - Fax:
Practice Address - Street 1:1353 N COURTENAY PKWY STE L
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4463
Practice Address - Country:US
Practice Address - Phone:321-978-5122
Practice Address - Fax:321-978-5127
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW14944101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health